Case summary A 62 year old gentleman was admitted to medical ward for 2 months history of generalized body weakness, anorexia, vague abdominal pain, fatigue and multiple erythematous, non-pruritic, scaly patches and plaques scattered throughout his body associated with nasal stuffiness. These lesions were hypoaesthetic. Blood investigations revealed a high corrected calcium level at 3.24 mmol/L which explained his acute medical complaints. Slit skin smear revealed Bacteriological Index (BI) of 1.2 and Morphological Index (MI) of 3.9. Skin biopsy confirmed the diagnosis of Borderline Lepromatous Leprosy. Institution of systemic steroids, vigorous intravenous fluid infusion and the implementation of multi-drug therapy for his leprosy resulted in a relatively swift decrease in reduction of calcium level. Conclusion This case report highlights the rare but important association of hypercalcaemia with leprosy. However, other granulomatous diseases such as sarcoidosis and tuberculosis have higher association with hypercalcaemia.

An invasive aspergillosis model in rabbits was attempted using 3 concentrations of A. fumigatus conidia. Conidia concentrations of 1 x 10(6), 1 x 10(7) and 1 x 10(8) were inoculated intravenously into rabbits. The severity of infection was directly proportional to the inoculum size of the conidia. Aspergillus fumigatus was isolated from livers, kidneys, spleens, hearts and lungs of infected rabbits at a rate of 82%, 75%, 57%, 54% and 32% respectively. Cultures of urine specimens taken by bladder tap were positive for A. fumigatus in 30% of the rabbits tested. Blood cultures using the Bactec Fungal System (Becton Dickinson Corp., USA) failed to isolate A. fumigatus in 20 rabbits with biopsy-proven invasive apergillosis. Active infection with high fungal tissue burden occurred between 2-4 days after infection in rabbits inoculated with 1 x 10(7) conidia.
Lower case ecks ; Infection as complication of medical care ; Models ; Aspergillosis ; Invasive

The ageing population is posing new challenges to Singapore's healthcare system. The rise of dual income and the decline of extended families, as well as an increase in age-related degenerative disorders due to increased longevity render it difficult for the family to remain the primary social safety net to care for our elderly in their own homes. Consequently, nursing homes may become increasingly relevant for resource and expertise-challenged families to cope with the burden of caring for a frail and dependent elderly. However, as the recent Nightingale Nursing Home elderly mistreatment incident attests, the standards of some have been found wanting. This paper will trace the history of nursing homes in Singapore and the evolution of government policies towards them, discuss the challenges and trade-offs of nursing home regulation, and provide suggestions for better care and governance.
Aged ; Forecasting ; Guidelines as Topic ; History, 20th Century ; History, 21st Century ; Humans ; Nursing Homes ; history ; legislation & jurisprudence ; standards ; trends ; Singapore

INTRODUCTIONThere is currently a lack of representative data for local gestational age-specific size-at- birth percentile charts. Existing charts also suffer from limitations relating to the measurement of gestational age (GA) and an outdated population. We aim to construct reference values and charts for size-at-birth from 35 to 41 weeks, based on the healthy local population.

MATERIALS AND METHODSProspective observational birth cohort study which recruited pregnant mothers from the 2 major public hospitals with obstetric service in Singapore, at <14 weeks gestation and data was collected for birth weight, length and head circumference of infants born from November 2009 to May 2011. Percentile curves were created separately for male and female infants using the lambda-mu-sigma (LMS) method. The new percentile curves were then compared with other internationally published growth charts.

RESULTSSmoothened curves for birth weight, length and head circumference centiles were created from 863 infants (460 males, 403 females). Male infants consistently exceeded female infants in all 3 variables at each GA. For a male and female Singapore infant at 38 weeks gestation, the 10-50-90th centile values for weight would be 2663-3096-3597 vs. 2571-2966-3417 grams, for length 46.4-48.6-51.1 vs. 45.6-48.0-50.4 cm, and for head circumference 32.0-33.5-35.2 vs. 31.4-32.9-34.6 cm. There was no statistically significant difference between ethnic groups. On comparing our birth weight curves with data from Finland across all gestations, birth weights in our term infants (GA ≥37 weeks) were found to be lower across the 10-50-90th percentiles.

CONCLUSIONThe new centile charts in this study may be used as reference charts for size-at-birth for a subgroup of near-term and term infants. The use of foreign charts may lead to misclassification of small for gestational age (SGA) or large for gestational age (LGA) infants.

Birth Weight ; Body Size ; Cephalometry ; Female ; Gestational Age ; Humans ; Infant, Newborn ; Male ; Prospective Studies ; Reference Values ; Singapore

INTRODUCTION: The impact of sex and diabetes mellitus (DM) on patients with heart failure with mildly reduced ejection fraction (HFmrEF) is not well elucidated. This study aims to evaluate sex differences in the clinical profile and outcomes in Asian HFmrEF patients with and without DM. METHODS: Patients admitted nationally for HFmrEF (ejection fraction 40-49%) between 2008 and 2014 were included and followed up until December 2016. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular (CV) death and/or heart failure (HF) rehospitalisations. RESULTS: A total of 2,272 HFmrEF patients (56% male) were included. More women had DM than men (60% versus 55%, P=0.013). Regardless of DM status, HFmrEF females were older, less likely to smoke, had less coronary artery disease, narrower QRS and lower haemoglobin compared to men. The odds of having DM decreases in smokers who are women as opposed to men (P_interaction =0.017). In multivariate analysis, DM reached statistical analysis for all-cause mortality and combined CV mortality or HF rehospitalisation in both men and women. However, the results suggest that there may be sex differences in terms of outcomes. DM (vs non-DM) was less strongly associated with increased all-cause mortality (adjusted hazards ratio [adj HR] 1.234 vs adj HR 1.290, P_interaction <0.001] but more strongly associated with the combined CV death/HF rehospitalisation (adj HR 1.429 vs adj HR 1.317, P_interaction =0.027) in women (vs men). CONCLUSION Asian women with HFmrEF had a higher prevalence of DM, with differences in clinical characteristics, compared to men. While diabetes conferred poor outcomes regardless of sex, there were distinct sex differences. These highlight the need for sex-specific management strategies.
Diabetes Mellitus/epidemiology* ; Female ; Heart Failure ; Humans ; Male ; Prognosis ; Stroke Volume ; Ventricular Dysfunction, Left/epidemiology* ; Ventricular Function, Left

Eribulin, an antimicrotubule chemotherapeutic agent, is approved for the treatment of pretreated metastatic breast cancer (mBC) based on the positive outcomes of phase II and phase III clinical trials, which enrolled mainly Western patients. Eribulin has recently been approved in an increasing number of Asian countries; however, there is limited clinical experience in using the drug in certain countries. Therefore, we established an Asian working group to provide practical guidance for eribulin use based on our clinical experience. This paper summarizes the key clinical trials, and the management recommendations for the reported adverse events (AEs) of eribulin in mBC treatment, with an emphasis on those that are relevant to Asian patients, followed by further elaboration of our eribulin clinical experience. It is anticipated that this clinical practice guide will improve the management of AEs resulting from eribulin treatment, which will ensure that patients receive the maximum treatment benefit.
Asian Continental Ancestry Group ; Breast Neoplasms* ; Breast* ; Drug Therapy ; Humans

INTRODUCTION: This study examined maternal, delivery and infant factors associated with cord thyroid-stimulating hormone (TSH) concentrations in an Asian population. METHODS: The Growing Up in Singapore Towards healthy Outcomes (GUSTO) study is a mother-offspring birth cohort from 2 major hospitals in Singapore. Cord serum TSH was measured using the Abbott ARCHITECT TSH Chemiluminescent Microparticle Immunoassay and the ADVIA Centaur TSH-3 Immunoassay. After excluding infants with a maternal history of thyroid disease, screening cord TSH results from 604 infants were available for multivariable regression analysis in relation to the factors of interest. RESULTS: Babies born by vaginal delivery had significantly higher cord serum TSH concentrations than babies born by caesarean section. Cord serum TSH concentrations differed significantly by measurement method. There was no association of cord TSH concentrations with ethnicity, sex, birth weight, gestational age, maternal body mass index, gestational weight gain, gestational diabetes mellitus status and other maternal, delivery and infant factors studied. CONCLUSION Interpretation of cord serum TSH results may need to take into account mode of delivery and measurement method.

INTRODUCTIONPre-hospital ambulance calls are not random events, but occur in patterns and trends that are related to movement patterns of people, as well as the geographical epidemiology of the population. This study describes the geographic-time epidemiology of ambulance calls in a large urban city and conducts a time demand analysis. This will facilitate a Systems Status Plan for the deployment of ambulances based on the most cost effective deployment strategy.

MATERIALS AND METHODSAn observational prospective study looking at the geographic-time epidemiology of all ambulance calls in Singapore. Locations of ambulance calls were spot mapped using Geographic Information Systems (GIS) technology. Ambulance response times were mapped and a demand analysis conducted by postal districts.

RESULTSBetween 1 January 2006 and 31 May 2006, 31,896 patients were enrolled into the study. Mean age of patients was 51.6 years (S.D. 23.0) with 60.0% male. Race distribution was 62.5% Chinese, 19.4% Malay, 12.9% Indian and 5.2% others. Trauma consisted 31.2% of calls and medical 68.8%. 9.7% of cases were priority 1 (most severe) and 70.1% priority 2 (moderate severity). Mean call receipt to arrival at scene was 8.0 min (S.D. 4.8). Call volumes in the day were almost twice those at night, with the most calls on Mondays. We found a definite geographical distribution pattern with heavier call volumes in the suburban town centres in the Eastern and Southern part of the country. We characterised the top 35 districts with the highest call volumes by time periods, which will form the basis for ambulance deployment plans.

CONCLUSIONWe found a definite geographical distribution pattern of ambulance calls. This study demonstrates the utility of GIS with despatch demand analysis and has implications for maximising the effectiveness of ambulance deployment.

Ambulances ; utilization ; Geographic Information Systems ; Singapore

Background/Aims: Data on treatment efficacy and safety of glecaprevir/pibrentasvir (GLE/PIB) for chronic hepatitis C virus (HCV) infection in Asian patients with severe renal impairment are limited. This study aimed to study the treatment and side effects of GLE/PIB in these patients infected with non-1 genotype (GT) HCV. Methods: We prospectively recruited patients with Child’s A cirrhosis and eGFR <30 mL/min/1.73 m2 in Hong Kong and Taiwan during 2017–2018 to receive GLE/PIB treatment. Results: Twenty-one patients (GT2, n=7; GT3, n=6; and GT6, n=8) received GLE/PIB for 11.2±1.8 weeks. All except one were treatment-naïve. GLE/PIB was initiated in 16 patients while on dialysis (seven on peritoneal dialysis [PD] and nine on hemodialysis) and in five patients before dialysis. One patient died of PD-related peritonitis during treatment and two were lost to follow up. The SVR12 rate in the remaining 18 patients was 100%. All patients achieved undetectable levels at 4-, 12-, 24- and 48-week after treatment. Patients with deranged alanine aminotransferase showed normalization after 4 weeks and the response was sustained for 48 weeks. No significant adverse event was observed. Conclusions GLE/PIB treatment was associated with high efficacy and tolerability in HCV-infected patients with severe renal impairment.

INTRODUCTIONBreast milk fatty acids play a major role in infant development. However, no data have compared the breast milk composition of different ethnic groups living in the same environment. We aimed to (i) investigate breast milk fatty acid composition of three ethnic groups in Singapore and (ii) determine dietary fatty acid patterns in these groups and any association with breast milk fatty acid composition.

MATERIALS AND METHODSThis was a prospective study conducted at a tertiary hospital in Singapore. Healthy pregnant women with the intention to breastfeed were recruited. Diet profile was studied using a standard validated 3-day food diary. Breast milk was collected from mothers at 1 to 2 weeks and 6 to 8 weeks postnatally. Agilent gas chromatograph (6870N) equipped with a mass spectrometer (5975) and an automatic liquid sampler (ALS) system with a split mode was used for analysis.

RESULTSSeventy-two breast milk samples were obtained from 52 subjects. Analysis showed that breast milk ETA (Eicosatetraenoic acid) and ETA:EA (Eicosatrienoic acid) ratio were significantly different among the races (P = 0.031 and P = 0.020), with ETA being the highest among Indians and the lowest among Malays. Docosahexaenoic acid was significantly higher among Chinese compared to Indians and Malays. No difference was demonstrated in n3 and n6 levels in the food diet analysis among the 3 ethnic groups.

CONCLUSIONSDifferences exist in breast milk fatty acid composition in different ethnic groups in the same region, although no difference was demonstrated in the diet analysis. Factors other than maternal diet may play a role in breast milk fatty acid composition.

Arachidonic Acids ; metabolism ; Breast Feeding ; ethnology ; Diet ; Diet Records ; Docosahexaenoic Acids ; metabolism ; Eicosapentaenoic Acid ; metabolism ; Ethnic Groups ; Fatty Acids ; metabolism ; Female ; Humans ; India ; ethnology ; Malaysia ; ethnology ; Maternal Welfare ; Milk, Human ; chemistry ; Nutritional Status ; Pregnancy ; Prenatal Nutritional Physiological Phenomena ; Prospective Studies ; Singapore ; Statistics, Nonparametric